Sometimes our
kids are injured no matter how many precautions we take and it’s our job to
find the best ways to treat these seriously injured children. The golden hour
is where you can intervene and improve outcomes from issues like airway
troubles, and blood loss, and that sort of thing. That's where, in the
emergency room, I come into play.
Dr. John Petty and I were talking and he brought up the fact that he sees many kids come
to the emergency department after trauma with low blood pressure but they have
not lost blood. In fact, oftentimes their primary and only injury is a
bad head injury.
In medical
school we are taught through the American College of Surgeon’s Advanced Trauma Life Support (ATLS) manual how to respond during that golden hour. It defines
the standards of care for trauma patients. It says that if we see evidence of
low blood pressure, or shock, that hemorrhage is what we're supposed to think.
They're losing blood somewhere. If it's not blood loss out of their body,
they're probably bleeding inside their abdomen or internally somehow. There is
a sentence in the manual that says isolated or intracranial injuries don't
cause shock.
Dr. Petty and
I discussed and decided this might be different for kids than adults, and we
decided to investigate because it might change our care. Instead of giving them
fluids and blood we might do something different to help their blood pressure.
In fact, if you've injured your brain, more fluids could cause the brain to
swell more and that would be detrimental.
We started a
very small study of patients that were treated at our Level I trauma center. We
reviewed the details of 31 kids with low blood pressure to see the final cause
of their injuries when they were discharge. We found that in kids under 5 years
old that came in with low blood pressure and evidence of shock, 50 percent of
the time they had an isolated head injury. They didn't have injuries that cause
internal blood loss.
The question
then becomes, what is the problem? That's guides our treatment. We found it was
age dependent. In kids 5 to 11 years old, we found that about 25 percent of
those kids had a head injury. This phenomenon disappeared in our teenagers.
After
discussion with colleagues at other institutions, we decided to expand our
study to review cases from the National Trauma Database. We don't know all the
answers to our questions yet, but more research is needed. We need to find
better ways to help save more injured kids during the crucial golden hour of
treatment. Head injury is a real problem in kids, and it's something that's not
entirely preventable.
Our
infectious disease colleagues began studying the causes of mortality in
pediatric patients decades ago and were able to develop vaccines and improve
antibiotics in the mid-1900s. We don't see kids dying a lot from infectious
disease anymore. Now we see the same thing with cancer. Childhood leukemia is
not a death sentence anymore, and that’s due to hard work in the mid-1980s and 1990s.
Their work is impactful.
Now childhood trauma is killing more kids than all other causes combined. I’m involved in the
care of these injured kids every day. Since we can’t completely prevent
injuries, it's our time to take on this challenge and help save the lives of
injured kids.
- Dr. AlisonGardner, Assistant Professor of Pediatrics and Emergency Medicine at Wake
Forest Baptist Medical Center
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